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Objectives:
To analyze the effectiveness of tai chi for falls prevention.
Design:
Systematic review and meta-analysis.
Setting:
Pubmed, Scopus, CINHAL, and Physiotherapy Evidence Database (PEDro) were searched to May 26, 2016.
Participants:
Older adult population and at-risk adults.
Intervention:
Randomized controlled trials analyzing the effect of tai chi versus other treatments on risk of falls.
Measurements:
The incidence rate ratio (IRR) for falls incidence and hazard ratio (HR) for time to first fall.
Results:
The search strategy identified 891 potentially eligible studies, of which 10 met the inclusion criteria. There was high-quality evidence of a medium protective effect for fall incidence over the short term (IRR = 0.57; 95% CI = 0.46, 0.70) and a small protective effect over the long term (IRR = 0.87; 95% CI = 0.77, 0.98). Regarding injurious falls, we found very low-quality evidence of a medium protective effect over the short term (IRR = 0.50; 95% CI = 0.33, 0.74) and a small effect over the long term (IRR = 0.72; 95% CI = 0.54, 0.95). There was no effect on time to first fall, with moderate quality of evidence (HR = 0.98; 95% CI = 0.69, 1.37).
Conclusion:
In at-risk adults and older adults, tai chi practice may reduce the rate of falls and injury-related falls over the short term (<12 months) by approximately 43% and 50%, respectively. Tai chi practice may not influence time to first fall in these populations. Due to the low quality of evidence, more studies investigating the effects of tai chi on injurious falls and time to first fall are required.

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... Although a previous meta-analysis revealed no effects of yoga on global cognitive function [14], our meta-analysis provides evidence of higher ES for EF from the prescription of both Tai Chi and yoga in older populations. This is an important finding with regard to exercise training interventions, because Tai Chi and yoga have been described as being more suitable than some other types of exercise for older adults because of the emphasis on slow controlled movements that result in a minimal risk of injury [53,54]. ...

Background
Chronic exercise training has been shown be to positively associated with executive function (EF) in older adults. However, whether the exercise training effect on EF is affected by moderators including the specific sub-domain of EF, exercise prescription variables, and sample characteristics remains unknown.Objectives
This systematic and meta-analytic review of randomized controlled trials (RCTs) investigated the effects of exercise training on EF in older adults and explored potential moderators underlying the effects of exercise training on EF.Methods
In accordance with the PRISMA guidelines, the electronic databases MEDLINE (PubMed) and EMBASE (Scopus) were searched from January 2003 to November 2019. All studies identified for inclusion were peer-reviewed and published in English. To be included, studies had to report findings from older (> 55 years old), cognitively normal adults or adults with mild cognitive impairment (MCI) randomized to an exercise training or a control group. The risk of bias in each study was appraised using the Cochrane risk-of-bias tool. Fixed-effects models were used to compare the effects of exercise training and control conditions on EF assessed at baseline and post-intervention. In addition, subgroup analyses were performed for three moderators (i.e., the specific sub-domain of EF, exercise prescription variables, and sample characteristics).ResultsThirty-three RCTs were included. Overall, exercise training was associated with a significant small improvement in EF [Q(106) = 260.09, Hedges’ g = 0.21; p < 0.01]. The EF sub-domain moderator was not significant [Q(2) = 4.33, p > 0.05], showing that the EF improvement in response to exercise is evident for measures of inhibition, updating, and shifting. Regarding exercise prescription variables, results were significantly moderated by frequency of exercise training [Q(1) = 10.86, p < 0.05], revealing that effect sizes (ESs) were larger for moderate frequency (g = 0.31) as compared to low frequency exercise (g = 0.15). The results also showed type of exercise training moderated the ESs [Q(4) = 26.18, p < 0.05], revealing that ESs were largest for other forms of exercise (g = 0.44), followed by Tai Chi and yoga (g = 0.38), resistance exercise (g = 0.22), aerobic exercise (g = 0.14), and combined exercise (g = 0.10). In addition, The results showed moderated length of training the ESs [Q(2) = 16.64, p < 0.05], revealing that ESs were largest for short length (g = 0.32), followed by mid length (g = 0.26) and long length (g = 0.09). No significant difference in effects was observed as a function of exercise intensity [Q(1) = 2.87 p > 0.05] and session time [Q(2) = 0.21, p > 0.05]. Regarding sample characteristics, the results were significantly moderated by age [Q(2) = 20.64, p < 0.05], with significant benefits for young-old (55–65 years old) (g = 0.30) and mid-old (66–75 years old) (g = 0.25), but no effect on EF for old-old (more than 75 years old). The results were also significantly moderated by physical fitness levels [Q(1) = 10.80, p < 0.05], revealing that ESs were larger for sedentary participants (g = 0.33) as compared to physically fit participants (g = 0.16). In addition, results were also significantly moderated by cognitive status [Q(1) = 11.44, p < 0.05], revealing that ESs were larger for participants with cognitively normal (g = 0.26) as compared to those with mild cognitive impairment (g = 0.08). No significant differences in effects were observed as a function of sex [Q(2) = 5.38, p > 0.05].Conclusions
Exercise training showed a small beneficial effect on EF in older adults and the magnitude of the effect was different across some moderators.

... 9,16 Thus, of the 3 exercise interventions, TJQMBB yielded the greatest reduction in number of falls, whereas both TJQMBB and multimodal exercise significantly improved physical function and global cognitive function compared with the stretching exercise control. The findings from this study are aligned with systematic review and meta-analyses on the effect of exercise on reducing the incidence of falls 7,26 and are commensurate with the results from a meta-analysis 27 and previous controlled tai ji quan studies involving community-dwelling older adults 13,28,29 and persons with Parkinson disease. 30 This clinically oriented and functionally driven tai ji quan-based program, 21 however, is shown to be more efficacious in the magnitude of reduction in the incidence of falls compared with earlier trial or meta-analysis results. ...

Importance
Falls in older adults are a serious public health problem associated with irreversible health consequences and responsible for a substantial economic burden on health care systems. However, identifying optimal choices from among evidence-based fall prevention interventions is challenging as few comparative data for effectiveness are available.
Objective
To determine the effectiveness of a therapeutically tailored tai ji quan intervention, Tai Ji Quan: Moving for Better Balance (TJQMBB), developed on the classic concept of tai ji (also known as tai chi), and a multimodal exercise (MME) program relative to stretching exercise in reducing falls among older adults at high risk of falling.
Design, Setting, and Participants
A single-blind, 3-arm, parallel design, randomized clinical trial (February 20, 2015, to January 30, 2018), in 7 urban and suburban cities in Oregon. From 1147 community-dwelling adults 70 years or older screened for eligibility, 670 who had fallen in the preceding year or had impaired mobility consented and were enrolled. All analyses used intention-to-treat assignment.
Interventions
One of 3 exercise interventions: two 60-minute classes weekly for 24 weeks of TJQMBB, entailing modified forms and therapeutic movement exercises; MME, integrating balance, aerobics, strength, and flexibility activities; or stretching exercises.
Main Outcomes and Measures
The primary measure at 6 months was incidence of falls.
Results
Among 670 participants randomized, mean (SD) age was 77.7 (5.6) years, 436 (65%) were women, 617 (92.1%) were white, 31 (4.6%) were African American. During the trial, there were 152 falls (85 individuals) in the TJQMBB group, 218 (112 individuals) in the MME group, and 363 (127 individuals) in the stretching exercise group. At 6 months, the incidence rate ratio (IRR) was significantly lower in the TJQMBB (IRR, 0.42; 95% CI, 0.31-0.56; P < .001) and MME groups (IRR, 0.60; 95% CI, 0.45-0.80; P = .001) compared with the stretching group. Falls were reduced by 31% for the TJQMBB group compared with the MME group (IRR, 0.69; 95% CI, 0.52-0.94; P = .01).
Conclusions and Relevance
Among community-dwelling older adults at high risk for falls, a therapeutically tailored tai ji quan balance training intervention was more effective than conventional exercise approaches for reducing the incidence of falls.
Trial Registration
ClinicalTrials.gov identifier: NCT02287740

... Some researcher [4,[11][12][13][14] have pointed out that there are effective ways to improve the static and dynamic balance in elderly people to reduce the fear of falls, and that training Tai Chi are proven to be effective than other training methods for preventing falls in at risk populations. Ancient Chinese Tai Chi practice reduces the risk of deadly falls by 43% and 50%, also that there are many factors for falling, and a great percentage of falls of elderly. ...

The purpose of this study is to design a daily training method or drill to prevent fall injure for people of all ages and gender. Most of these falls are from slips, accidents, unsteady gaits, weaknesses or due to certain medications. Some researchers have pointed out that there are effective ways to improve the static and dynamic balance in elderly people to reduce fear of falling, and training Tai Chi were proven to be effective than other measures for preventing falls in at risk populations.

... One meta-analysis examined the effect of Tai-Chi on the incidence of falls and time to first fall in adults aged 56 to 98 years compared to usual care or other interventions in 10 randomised controlled trials 18 . Interventions were typically of 1-hour duration and delivered at a frequency of 1-3 times per week for 12-26 weeks. ...

Many activities of daily living require muscular strength and power as well as balance. Consequently, preserving musculoskeletal function is a prerequisite for maintaining mobility and independent living during ageing. Estimates suggest that the prevalence of physical activity guidelines for strength and balance is low. Review of reviews of: a) observation studies of the prospective association between measures of musculoskeletal fitness and health outcomes and b) randomised controlled trials of resistance, balance and skeletal impact training exercises on bone health, risk of falls, physical function, motor and cognitive function, quality of life and activities of daily living. Preserving muscular strength/power in middle and older age is associated with a reduced risk of all-cause and cardiovascular mortality. Impaired muscular strength/power and balance is associated with an increased risk of falls and lower bone mineral content. Regular supervised exercise incorporating high intensity resistance training, vertical impacts and a balance challenge are most likely to be beneficial to health and wellbeing, bone health and reduce the risks of falls. Adults in late middle and older age would benefit from a regular program of exercise that incorporates high intensity resistance training, impact exercises and balance challenges.

... Among the existing strategies for the prevention of falls, exercise-only interventions appear to be the best possible approach at the moment, with comparable results to a multicomponent intervention (Sherrington, Tiedemann, Fairhall, Close, & Lord, 2011). In recent years, new types of exercise training programmes have been suggested to positively contribute to the prevention of falls (Lomas-Vega, Obrero-Gaitán, Molina-Ortega, & Del-Pino-Casado, 2017;Ma, Liu, Sun, Zhu, & Wu, 2016). One on the latest training trends is the Pilates method. ...

Objective:
the main objective was to analyze the effects that an exercise programme based on the Pilates method would have on balance confidence, fear of falling, and postural control among women ≥60 years old.
Methods:
a total of 110 women (69.15 ± 8.94 years) participated in this randomized, controlled trial that took place in Jaén (Spain). The participants were randomly assigned to either a control group (n = 55), which received no intervention, or to a Pilates group (n = 55), which carried out an exercise programme based on the Pilates method in 60-minute sessions for 12 weeks. The Falls Efficacy Scale-International and the activity-specific balance confidence scale were respectively used to assess fear of falling and balance confidence in performing activities of daily living. Postural control was evaluated using a stabilometric platform.
Results:
Regarding balance confidence, the Pilates group showed higher values compared to the control group (77.52 ± 18.27 vs 72.35 ± 16.39, Cohen's d = 0.030). Women in the Pilates group showed lower fear of falling, compared to those of the control group (22.07 ± 5.73 vs 27.9 ± 6.95, Cohen's d = 0.041). Finally, concerning static balance, participants of the Pilates group experienced statistically significant improvements on the velocity and anteroposterior movements of the centre of pressure with eyes open and closed respectively (Cohen's d = 0.44 and 0.35 respectively).
Conclusion:
A 12-week Pilates training programme has beneficial effects on balance confidence, fear of falling and postural stability, in elderly women.

... Metaanalysis studies demonstrated that Tai Chi could improve physical capabilities and reduce risks and rates of falls in elderly people. [30][31][32] However, RCT studies showed that effects of Tai Chi on fall risks were not different compared to other exercises. 33,34 Effects of Yoga in reducing fall risks have also been widely investigated. ...

... So far, we did a search of related SRs and retrieved 18 published meta-analyses. [23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40] We used A Measurement Tool to Assess systematic Reviews 2.0 (AMSTAR 2.0) [41] to evaluate the quality of 18 included metaanalyses. The results of AMSTAR 2.0 showed that 17 SRs were considered critically low methodological quality and 1 SR was DZ, QX, and MH contributed equally to this work. ...

Introduction:
To investigate the effectiveness and safety of Tai Chi for improving balance and reducing falls on people.
Methods and analysis:
The following databases will be searched: China Biology Medicine (CBM), China National Knowledge infrastructure (CNKI), Wan Fang Data, the Chinese Science and Technology Periodical Database (VIP), Medline, EMBASE, Web of Science, The Cochrane Library from inception to March 2019. All randomized controlled trials (RCTs) utilized Tai Chi to improve balance ability and reduce falls will be included. Primary outcomes are the fall-related indicators, including the number of falls, fall rate, and other fall-related outcomes. Additional outcomes include the Berg Balance Scale (BBS), standing-walk test, single-legged time, or other balance-related outcomes. Study selection, data extraction, and quality assessment will be performed independently by 2 reviewers. Assessment of risk of bias and data synthesis will be performed using Review Manager V5.3 software.
Ethics and dissemination:
The findings of this systematic review will be disseminated through peer-reviewed publication or conference presentations.Trial registration number PROSPERO CRD42019127810.

... Falls which many times occur with elderly adults have been implicated as the second highest cause of disability and death in this age group [1]. In part, these events derive from the aging process which is accompanied by structural and functional organic changes that restrict the effectiveness of most of daily actions which many elderlies are subject on their common life, including an ample class of motor activities [2]. ...

... Many clinical trials evaluating the effects of TC training on balance, mobility, physical function, and fall prevention in older adults have demonstrated clinically meaningful and sometimes quite large benefits. [21][22][23][24] However, a small number of well-designed and adequately powered studies indicate no apparent benefit of TC. [25][26][27][28] Explaining lack of effectiveness in any one of these trials, including the present study, is difficult because comparisons of interventions such as TC are likely confounded by differences in study design, eligibility criteria, interventions (ie, TC style and specific forms), control groups, duration and intensity of exposure, quality and fidelity of instruction, and intervention adherence rates. [29][30][31] Our previous pilot study targeted a similar population of frail older adults living in senior housing facilities and demonstrated significant improvements in SPPB (11%) and TUG (7%) scores among participants receiving TC training over just 12 weeks. ...

OBJECTIVES
Tai Chi (TC) may benefit older adults with a variety of diseases and disabilities. We tested the hypothesis that TC improves physical function in older adults living in low‐income housing facilities.
DESIGN
Cluster randomized controlled trial.
SETTING
Subsidized housing facilities in Boston, Massachusetts, and neighboring communities.
PARTICIPANTS
Volunteers were recruited from 15 facilities. The 180 randomized participants were 60 years of age or older, able to understand English and participate in TC, expected to remain in the facility for 1 year, and able to walk independently.
INTERVENTION
TC classes were conducted in the housing facilities twice/week for 1 year and compared with monthly health promotion educational classes and social calls.
MEASUREMENTS
The primary outcome was physical function measured by the Short Physical Performance Battery (SPPB). Secondary outcomes included other aspects of physical and cognitive function, and falls.
RESULTS
An interim analysis revealed less improvement over 12 months in SPPB scores among TC participants (+.20 units; 95% confidence interval [CI] = −.20 to +.60; P = .69) vs control participants (+.51 units; 95% CI = +.15 to +.87; P = .007), a difference of −.31 units (95% CI = −.66 to .04; P = .082). This met the criterion for futility, and the Data Safety Monitoring Board recommended trial termination. No differences were found in 6‐ or 12‐month changes favoring TC in any secondary outcomes or adverse events.
CONCLUSION
In older adults with multiple chronic conditions living in subsidized housing facilities, 6 and 12 months of twice/week TC classes were not associated with improvements in functional health.

... The interventions focused on the realisation of physical activity have shown their effectiveness, and that it is possible to delay and, in many cases, reverse fragility and dependence. The same goes for the practice of Tai-Chi, which can help reduce the risk of suffering a fall in the older adult population [23,24]. However, despite the fact that we carry out preventive interventions and work on the physical condition of the elderly, they will still be subject to the risk of falling and this is where JUA represents a unique intervention, proposing strategies of action to fall safely and securely, to retain mobility on the ground (once the fall has occurred) and to get back to a standing position. ...

This article reports on the Adapted Utilitarian Judo project. The use of the foundations and technical elements of traditional Judo, adapted and contextualised to the requirements of the older adult population, orienting the activity toward the field of health and the improvement of the quality of life of the older adult. Its mission is to facilitate maintaining and improving the functionality and autonomy of this population, with respect to the performance of the basic and instrumental activities of daily life. At the same it seeks to achieve this while maintaining the essence of the values that are inherent to the practice of Judo as a traditional martial art. It is argued that Judo, once adapted to focus on a utilitarian function, not only allows to actively influence aspects such as maintaining the physical qualities of the elderly but also fosters other key elements for active and healthy ageing by participating in an ongoing group activity, such as socialisation and self-esteem. More specifically, the paper presents how adapted Judo represents an innovation in the treatment of a risk factor associated with aging: the active prevention of falls. We conclude that Adapted Utilitarian Judo (JUA) is both a timely and relevant as a social and educational tool of great value, responds to propos called for by the international scientific community for programs aimed at improving the health and quality of life of the older adult population, especially in Europe, that is ageing at a fast pace.

... With great interest we read the recently published meta-analysis of studies of Tai Chi for reducing falls. 1 Although the authors used sound methods in reporting and grading the studies' qualities, we believe that the presented data do not correctly reflect the existing evidence and that more is needed for the clinical interpretation of these findings to enable clinicians and practitioners to develop effective fall-preventive programs. ...

... It was also a feasibility study for a subsequent definitive trial to test the effect of Tai Chi on preventing falls among PWD. Systematic reviews have shown that Tai Chi is an effective exercise-based intervention for preventing falls among older people, 8 frail and at-risk older adults, 17,18 and older people with Parkinson's disease and stroke. 19 We report the first randomised controlled trial to test if Tai Chi can improve postural balance among PWD, and the future definitive trial will be the first to test if Tai Chi can prevent falls among PWD. ...

Purpose:
To investigate the effect of Tai Chi exercise on postural balance among people with dementia (PWD) and the feasibility of a definitive trial on falls prevention.
Patients and methods:
Dyads, comprising community-dwelling PWD and their informal carer (N=85), were randomised to usual care (n=43) or usual care plus weekly Tai Chi classes and home practice for 20 weeks (n=42). The primary outcome was the timed up and go test. All outcomes for PWD and their carers were assessed six months post-baseline, except for falls, which were collected prospectively over the six-month follow-up period.
Results:
For PWD, there was no significant difference at follow-up on the timed up and go test (mean difference [MD] = 0.82, 95% confidence interval [CI] = -2.17, 3.81). At follow-up, PWD in the Tai Chi group had significantly higher quality of life (MD = 0.051, 95% CI = 0.002, 0.100, standardised effect size [ES] = 0.51) and a significantly lower rate of falls (rate ratio = 0.35, 95% CI =0.15, 0.81), which was no longer significant when an outlier was removed. Carers in the Tai Chi group at follow-up were significantly worse on the timed up and go test (MD = 1.83, 95% CI = 0.12, 3.53, ES = 0.61). The remaining secondary outcomes were not significant. No serious adverse events were related to participation in Tai Chi.
Conclusion:
With refinement, this Tai Chi intervention has potential to reduce the incidence of falls and improve quality of life among community-dwelling PWD [Trial registration: NCT02864056].

... 6 One type of exercise intervention that has gained attention in reducing falls risk is Tai Chi. [7][8][9][10][11][12] Tai Chi is an ancient Chinese martial art that employs slow and rhythmic movements that emphasizes the participants' body awareness, postural alignment, and limb coordination. It is particularly useful as an exercise intervention as it does not require special equipment, which makes it easier to implement into the community. ...

... [9][10][11] It is one of the non-pharmacological therapies recommended by the American College of Rheumatology for the treatment of KOA. 12 Tai chi has also been shown to reduce fall risk in the ageing population. 13 Despite common recommendations of tai chi for balance control and fall reduction, the neuromechanical mechanisms underlying these benefits are not clearly understood. ...

Introduction:
Stair ascent and descent require complex integration between sensory and motor systems; individuals with knee osteoarthritis (KOA) have an elevated risk for falls and fall injuries, which may be in part due to poor dynamic postural control during locomotion. Tai chi exercise has been shown to reduce fall risks in the ageing population and is recommended as one of the non-pharmocological therapies for people with KOA. However, neuromuscular mechanisms underlying the benefits of tai chi for persons with KOA are not clearly understood. Postural control deficits in performing a primary motor task may be more pronounced when required to simultaneously attend to a cognitive task. This single-blind, parallel design randomised controlled trial (RCT) aims to evaluate the effects of a 12-week tai chi programme versus balance and postural control training on neuromechanical characteristics during dual-task stair negotiation.
Methods and analysis:
Sixty-six participants with KOA will be randomised into either tai chi or balance and postural control training, each at 60 min per session, twice weekly for 12 weeks. Assessed at baseline and 12 weeks (ie, postintervention), the primary outcomes are attention cost and dynamic postural stability during dual-task stair negotiation. Secondary outcomes include balance and proprioception, foot clearances, self-reported symptoms and function. A telephone follow-up to assess symptoms and function will be conducted at 20 weeks. The findings will help determine whether tai chi is beneficial on dynamic stability and in reducing fall risks in older adults with KOA patients in community.
Ethics and dissemination:
Ethics approval was obtained from the Ethics Committee of the Affiliated Rehabilitation Hospital of Fujian University of Traditional Chinese Medicine (#2018KY-006-1). Study findings will be disseminated through presentations at scientific conferences or publications in peer-reviewed journals.
Trial registration number:
ChiCTR1800018028.

... The coordinated and balanced movements of TC promote efficiency of movement and economy of effort that is ideal for falls prevention. [6][7][8] It provides benefit for many chronic health conditions seen in older adults and offers psychological, social and health promotion benefits. 5,6 TC is a mild-to-moderate aerobic exercise depending on style (lineage) or health status of the participant. ...

... 18 TC includes gentle movements that may simulate activities of daily living. At least some evidence suggests TC may be effective for improving balance 19 and fall prevention, 20 congestive heart failure, 21 bone health, 22 osteoarthritis, 23,24 and depression, 25 conditions that are more common in older adults. We are unaware of studies of TC for cLBP that focused on older adults (and it is unclear if any were included in the published trials). ...

Objectives:
T'ai chi (TC) has been found effective for improving chronic low back pain (cLBP). However, such studies did not include adults over 65 years of age. This study was designed to evaluate the feasibility and acceptability of TC in this population compared with Health Education (HE) and with Usual Care (UC).
Design:
Feasibility randomized controlled trial.
Settings/Location:
Participants were recruited from Kaiser Permanente Washington and classes took place in a Kaiser facility.
Patients:
Adults 65 years of age and older with cLBP.
Interventions:
Twenty-eight participants were randomized to 12 weeks of TC followed by a 24-week tapered TC program, 12 were assigned to a 12-week HE intervention and 17 were assigned to UC only.
Outcome Measures:
Feasibility and acceptability were determined by recruitment, retention and 12-, 26-, and 52-week follow-up rates, instructor adherence to protocol, class attendance, TC home practice, class satisfaction, and adverse events.
Results:
Fifty-seven participants were enrolled in two cohorts of 28 and 29 during two 4-month recruitment periods. Questionnaire follow-up completion rates ranged between 88% and 93%. Two major class protocol deviations were noted in TC and none in HE. Sixty-two percent of TC participants versus 50% of HE participants attended at least 70% of the classes during the 12-week initial intervention period. Weekly rates of TC home practice were high among class attendees (median of 4.2 days) at 12 weeks, with fewer people practicing at 26 and 52 weeks. By 52 weeks, 70% of TC participants reported practicing the week before, with a median of 3 days per week and 15 min/session. TC participants rated the helpfulness of their classes significantly higher than did HE participants, but the groups were similarly likely to recommend the classes.
Conclusion:
The TC intervention is feasible in this population, while the HE group requires modifications in delivery.

... The high plantar loading in the forefoot indicates a strategy so that elderly can maintain balance [47]. These findings may support the idea that Tai Chi can improve balance during walking, which is in agreement with those of previous studies demonstrating that Tai Chi reduces the risk of falling in older adult population [48,49]. ...

Tai Chi is an available method for the treatment of knee osteoarthritis (KOA). The impacts of Tai Chi on plantar loads of individuals with KOA are not fully understood. 46 participants with knee osteoarthritis were randomly assigned into the Tai Chi group (n=23) or the control group (n=23). The Tai Chi group attended a 6-month Tai Chi program, and the control group participated in a wellness education program. Novel Pedar-X system was used to collect the peak pressure (PP) and maximum force (MF) during walking before and 6 months after the intervention. Significant higher peak pressure and maximum force were observed in the 4th and 5th metatarsophalangeal joints in the Tai Chi group. However, there were significant declines in the peak pressure of the whole foot and the 2nd and 3rd metatarsophalangeal joints and maximum force of the heel in the control group. These results suggested that individuals with KOA might change the pattern of plantar loads during walking through Tai Chi, and plantar loads would be useful as a parameter to assess the effect of Tai Chi on knee osteoarthritis. This trial is registered with Clinical Trials: CHiCTR-TRC-13003264.

Tai-Chi (TC) practice has been increasingly used to prevent falls in older adults. However, the biomechanical mechanisms underlying the effects of TC practice on fall risk among older adults remain unanswered. The objective of this pilot study was to examine how TC gait biomechanically impacts the human body in terms of dynamic gait stability and lower limb muscle strength in comparison with regular walking gait. Ten healthy adults performed five trials of TC gait following three to five trials of regular walking. Full body kinematics and kinetics were collected, and then dynamic gait stability and lower limb joint moments were determined. During TC gait, individuals were less stable, moved more slowly and experienced a larger mediolateral movement in comparison with regular walking gait. The peak moment at the ankle joint on the sagittal and transverse planes, at the knee joint on all three planes, and at the hip joint on the frontal plane was significantly different when performing TC gait than during regular gait. The results indicate that TC gait challenges body balance and requires more muscle strength of the lower limb joints compared to regular walking gait. To cope with these challenges, the body could develop neuromuscular control strategies to maintain body balance and thus reduce the risk of falls. The findings and methodology in this study could provide preliminary guidance for identifying optimal TC forms in order to maximize the effects of TC-based fall prevention interventions among various populations with elevated risk of falls.

On a global basis, adults 65 years of age and older experience falls more frequently than younger individuals, and these often result in severe injuries as well as increased healthcare costs. Gait and balance disorders in this population are among the most common causes of falls and negatively influence quality of life and survivorship. Although falls are a major public health problem and guidelines/recommendations are available to physicians, many are fully aware of different assessments, tools, and resources available for intervention. Given the risk for potentially devastating outcomes if severe injuries occur secondary to a fall, fall prevention strategies in clinical offices is a timely consideration in today's health care landscape. This paper presents a three-tier model, comprising assessment, prevention, and intervention, to highlight methods, proactive programs, and innovative tools and technology that have been developed for fall prevention. Awareness of these resources will enhance the clinician's ability to accurately assess balance and gait, which can improve physical function, and decrease the risk of falls for both average-risk and high-risk older adults.

Purpose of Review
Tai Chi (TC) is expanding as a holistic intervention. The purpose of this paper is to provide a historical perspective on TC and how its original preventative tenants can be applied today. TC can go far beyond its accepted use for balance and falls prevention and has benefits for a wide variety of physical, mental, and social health conditions common with aging.
Recent Findings
Using current (last 5 years) evidence from PubMed (meta-analyses and systematic reviews), the merits of TC as an integrative intervention and preventative tool are analyzed by key causes of mortality and morbidity found in older adults.
Summary
TC is a readily adaptable exercise accessible to a wide variety of ages and skill levels. Traditional free-standing TC can be modified to seated, standing with side support, and or walker support versions. TC can be used in individual or group community-based settings to promote wellness.

Exercise can be used to treat various chronic diseases and health conditions. This chapter first presents and summarizes the exercise prescription recommendations, following the frequency, intensity, time, and type principle from international professional committees and organizations for five chronic diseases/health conditions. Second, through a case study approach, this chapter introduces an evidence-based decision support system to guide health-care and exercise professionals to design an exercise prescription for individuals with multiple chronic diseases and health conditions.

Background and objectives:
Falls among older adults is a pressing public health challenge. Considerable research documents that longer tai chi courses can reduce falls and improve balance. However, longer courses can be challenging to implement. Our goal was to evaluate whether a short 6-week modified tai chi course could be effective at reducing falls risk if older adults designed a personal home practice plan to receive a greater tai chi "dose" during the 6 weeks.
Design:
A 3-city wait-listed randomized trial was conducted. Habituation Intention and Social Cognitive Theories framed the "coaching" strategy by which participants designed practice plans. RE-AIM and Treatment Fidelity Frameworks were used to evaluate implementation and dissemination issues. Three advisory groups advised the study on intervention planning, implementation, and evaluation. To measure effectiveness, we used Centers for Disease Control and Prevention recommended measures for falls risk including leg strength, balance, and mobility and gait. In addition, we measured balance confidence and executive function.
Results:
Program Implementation resulted in large class sizes, strong participant retention, high program fidelity and effectiveness. Participants reported practicing an average of 6 days a week and more than 25 min/day. Leg strength, tandem balance, mobility and gait, balance confidence, and executive function were significantly better for the experimental group than control group.
Conclusion:
The tai chi short course resulted in substantial tai chi practice by older adults outside of class as well as better physical and executive function. The course reach, retention, fidelity, and implementation across 3 cities suggest strong potential for implementation and dissemination of the 6-week course.

Background:
Mind-body exercise interventions are typically multimodal, complex, and pluralistic, and few have been developed with the goal of therapeutically targeting a specific medical population. It is thus important that clinical trials evaluating mind-body interventions provide some justification for the use of the specific protocol being evaluated.
Objectives:
This article reports the results of a systematic review of the quality of reporting of protocol rationale and content validity for using a specific t'ai chi protocol in a randomized controlled trial (RCT).
Methods:
Electronic literature searches were conducted using PubMed/MEDLINE, EBSCOhost, and the Cochrane Library from inception through June 2015. Search terms were Tai Chi, Taiji, Tai Chi Chuan; searches were limited to English-language RCTs. Inclusion and exclusion of trials were reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The authors assessed the level of reporting with respect to t'ai chi protocol validation using a 5-point grading system based on whether (1) a specific protocol was mentioned, (2) rationale for the specific protocol was stated and supported, and (3) formal evaluation for content validity was conducted.
Results:
There was significant heterogeneity in the quality of reporting related to protocol rationale and content validity. A total of 171 publications were identified. Studies met between 0 and 4 validity criteria (of possible 5, more indicating better quality), with a mean of 2.52 (±SD 1.2) and median of 3. Twenty (12%) trials did not mention a specific t'ai chi protocol, 10 (6%) trials met 0 of 5 criteria, and 47 (31%) studies met 4 of 5 criteria. Formal validity assessments were employed in only one trial.
Conclusions:
The poor quality of protocol rationale and content validity reporting limits our ability to accurately evaluate the evidence of t'ai chi as a therapeutic intervention. The development of formal guidelines for developing and reporting intervention validity for multimodal mind-body exercises like t'ai chi may improve the quality and interpretability of research.

Dual-task (DT) training, which impacts both motor and cognitive function, has so far rarely been included in fall prevention research even so cognitive impairment, including attentional deficits, represents a potential high-impact pathway for risk of falling in older persons. This chapter systematically reviews the literature and appraises previous interventional trials that have used DT training approaches for fall prevention. Future research needed is addressed.

Falls are prevalent in older people and frequently have serious consequences including injury, hospitalization, reduced mobility and independence, and increased health-care costs. A broad range of risk factors predispose older adults to falling, including underlying medical conditions, balance and gait instability, polypharmacy, and environmental hazards. A multifactorial fall risk assessment including fall history, physical exam, gait and balance evaluation, and environmental assessment is recommended for all older adults who present for medical evaluation with a fall or with balance and gait problems. Evidence-based fall risk screening tools are available for community, hospital, and long-term care facilities to aid in fall risk evaluations. Single intervention strategies to prevent falls in community-dwelling adults include exercise (including balance and gait training), medication management, vitamin D supplementation, expedited cataract surgery, cardiovascular interventions, and environmental and safety precautions. Multifactorial interventions and programs including several strategies tailored to individual fall risk assessments are most effective in preventing falls in high-risk patients living in the community and long-term care settings.

Americans are suffering from a culture of taking pills. Six out of ten Americans utilize at least one prescription drug, and more than one in ten use five or more prescription medicines. Although this torrent of taking pills is already high, drug use in the USA has not yet crested. Prescription drugs have specific targets, but often they adversely affect other tissues and organs. In keeping with the mission of the recently named National Center for Complementary and Integrative Health (NCCIH), Brain, Behavior, and Immunity searches for the underlying cause and potential efficacy of both drug and non-drug interventions. When the journal was first published in 1987, it challenged the scientific tidal wave that emphasized specialization in a single, specific discipline such as molecular biology, neuroscience or immunology. The focus of the journal was to support and extend biomedical research by publishing cutting edge findings in psychoneuroimmunology. Brain, Behavior, and Immunity began serving as the official journal of the Psychoneuroimmunology Research Society (PNIRS) in 2000. During its first 16 years of existence, Brain, Behavior, and Immunity published 600 papers. During the subsequent 15 years, there has been a steep, linear rise in publications that continues to this day, amounting to the publication of nearly 2,500 articles in psychoneuroimmunology. Some of the current and hottest topics in the field are investigating ancient health practices such as mindfulness-based meditation, Tai Chi, exercise, perinatal health and the gut microbiome. As such, Brain, Behavior, and Immunity continues to advance biomedical research by boldly going forward. Just as it originally challenged the specialization philosophy that is so prevalent in medicine, it is now exploring the integrative physiological events that underlie century-old health practices. This approach has revealed that some age-old interventions are just as efficacious as prescription drugs. A world in which century-old therapies meet modern technologies could well be the best medicine for all of us.

Falls amongst older people is a global public health concern. Whilst falling is not a typical feature of ageing, older people are more likely to fall. Fall injuries amongst older people are a leading cause of death and disability. Many older people do not do regular exercise so that they lose muscle tone, strength, and flexibility which affect balance and predispose them to falls. The management of falls in residential care settings is a major concern with strategies for prevention and monitoring a focus in this setting. Yoga and tai chi have shown potential to improve balance and prevent falls in older adults. They also have potential to improve pain and quality of life. The aim of this study was to determine the feasibility of conducting a three-arm randomised controlled trial (RCT) with frail older people in a residential care setting to test the hypothesis that a 14-week modified tai chi or yoga programme is more effective than usual care activity in improving balance function, quality of life, pain experience and in reducing number of falls. There were no statistically significant differences between the three groups in the occurrence of falls. Yoga demonstrated a slight decrease in fall incidence; quality of life improved for the tai chi group. Only the yoga group experienced a reduction in average pain scores though not statistically significant. The findings of the study suggest it is possible to safely implement modified yoga and tai chi in a residential care setting and evaluate this using RCT design. They show positive changes to balance, pain and quality of life and a high level of interest through attendance amongst the older participants. The results support offering tai chi and yoga to older people who are frail and dependent with physical and cognitive limitations.

UNLABELLED: OBJECTIVE To identify scientific publications about falls among non-institutionalized Spanish elderly population and to summarize the study findings which analysed the incidence, the risk factors and the consequences of the falls in the geriatric spanish population aged 65 years and over who lives institutionalized in our country.

Tai Chi has frequently been used as a preventive measure against falling in at-risk populations. However, studies have yielded contradictory results, and literature reviews have considered only a small number of trials and have not addressed some key aspects, such as sources of heterogeneity and publication bias. This study includes 13 controlled trials published before June 2015 that analyzed the effectiveness of Tai Chi in fall prevention in populations of frail and at-risk adults. The effect measure used in this meta-analysis was absolute risk reduction (ARR) with a 95% confidence interval (CI). According to our findings, practice of Tai Chi significantly prevents the risk of falling (ARR, [Formula: see text]; 95% CI: [Formula: see text], [Formula: see text]). The heterogeneity of results across the trials was low, with a reduced risk of publication bias, and no significant effect differences were observed between studies comparing Tai Chi with other interventions or non-treatment. We therefore conclude that Tai Chi is more effective than other measures, or no intervention, for fall prevention in at-risk populations. Further research is warranted to analyze the consequences of falls and to study the episodes rather than the cases of falls.

Introduction:
This study sought to estimate the incidence, average cost, and total direct medical costs for fatal and non-fatal fall injuries in hospital, ED, and out-patient settings among U.S. adults aged 65 or older in 2012, by sex and age group and to report total direct medical costs for falls inflated to 2015 dollars.
Method:
Incidence data came from the 2012 National Vital Statistics System, 2012 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample, 2012 Health Care Utilization Program National Emergency Department Sample, and 2007 Medical Expenditure Panel Survey. Costs for fatal falls were derived from the Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System; costs for non-fatal falls were based on claims from the 1998/1999 Medicare fee-for-service 5% Standard Analytical Files. Costs were inflated to 2015 estimates using the health care component of the Personal Consumption Expenditure index.
Results:
In 2012, there were 24,190 fatal and 3.2 million medically treated non-fatal fall related injuries. Direct medical costs totaled $616.5 million for fatal and $30.3 billion for non-fatal injuries in 2012 and rose to $637.5 million and $31.3 billion, respectively, in 2015. Fall incidence as well as total cost increased with age and were higher among women.
Conclusion:
Medically treated falls among older adults, especially among older women, are associated with substantial economic costs.
Practical application:
Widely implementing evidence-based interventions for fall prevention is essential to decrease the incidence and healthcare costs associated with these injuries.

To compare the effects of guided home-based tai chi chuan (TCC) and lower extremity training (LET) and of levels of self-practice on falls and functional outcomes in older fallers. Randomized controlled trial. Taipei, Taiwan. Individuals aged 60 and older who had fall-related emergency department visits at least 6 months before participating in the study and ambulated independently at baseline (N = 456). Six months of TCC or LET. Four types of fall measures (falls, time to first fall, fallers, recurrent fallers) and six functional measures (handgrip strength, balance, mobility, fear of falling, depression, cognitive function). The TCC group was significantly less likely than the LET group to experience any falls during the 6-month intervention (incidence rate ratio (IRR) = 0.30, 95% confidence interval (CI) = 0.15–0.60), and the effects remained significant after 12 months of follow-up (IRR = 0.32, 95% CI = 0.14–0.71). These effects remained significant for injurious falls during the 6-month intervention (IRR = 0.33, 95% CI = 0.16–0.68) and the entire 18-month study (IRR = 0.39, 95% CI = 0.18–0.83). Similar results were obtained when another two fall measures (time to first fall, number of fallers) were used. Moreover, participants who independently practiced TCC or LET seven times per week or more were significantly less likely to experience injurious falls during the 6-month intervention (IRR = 0.41, 95% CI = 0.20–0.83) and the 18-month study (IRR = 0.43, 95% CI = 0.21–0.87) than their counterparts, had a significantly longer time to first injurious fall, and were significantly less likely to have an injurious fall during the 6-month intervention. Cognitive function improved to a greater extent in the TCC group than in the LET group over the 18-month study. Home-based TCC may reduce the incidence of falls and injurious falls more than conventional LET in older fallers, and the effects may last for at least 1 year.

Objective To examine the effects of stepping interventions on fall risk factors and fall incidence in older people.
Data source Electronic databases (PubMed, EMBASE, CINAHL, Cochrane, CENTRAL) and reference lists of included articles from inception to March 2015.
Study selection Randomised (RCT) or clinical controlled trials (CCT) of volitional and reactive stepping interventions that included older (minimum age 60) people providing data on falls or fall risk factors.
Results Meta-analyses of seven RCTs (n=660) showed that the stepping interventions significantly reduced the rate of falls (rate ratio=0.48, 95% CI 0.36 to 0.65, p<0.0001, I2=0%) and the proportion of fallers (risk ratio=0.51, 95% CI 0.38 to 0.68, p<0.0001, I2=0%). Subgroup analyses stratified by reactive and volitional stepping interventions revealed a similar efficacy for rate of falls and proportion of fallers. A meta-analysis of two RCTs (n=62) showed that stepping interventions significantly reduced laboratory-induced falls, and meta-analysis findings of up to five RCTs and CCTs (n=36–416) revealed that stepping interventions significantly improved simple and choice stepping reaction time, single leg stance, timed up and go performance (p<0.05), but not measures of strength.
Conclusions The findings indicate that both reactive and volitional stepping interventions reduce falls among older adults by approximately 50%. This clinically significant reduction may be due to improvements in reaction time, gait, balance and balance recovery but not in strength. Further high-quality studies aimed at maximising the effectiveness and feasibility of stepping interventions are required.
Systematic reviews registration number CRD42015017357.

Systematic reviews and meta-analyses are essential to summarize evidence relating to efficacy and safety of health care interventions accurately and reliably. The clarity and transparency of these reports, however, is not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users.Since the development of the QUOROM (QUality Of Reporting Of Meta-analysis) Statement--a reporting guideline published in 1999--there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realizing these issues, an international group that included experienced authors and methodologists developed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions.The PRISMA Statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this Explanation and Elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA Statement, this document, and the associated Web site (http://www.prisma-statement.org/) should be helpful resources to improve reporting of systematic reviews and meta-analyses.

The expected increase in the US older adult population implies an increased risk of fall-related injury among these individuals. We describe the epidemiology of fall morbidity among older adults in Texas, a large US state with a diverse population base.
Texas Behavioral Risk Factor Surveillance System 2010 data were analyzed. The falls outcome was defined as falling: any fall in the past 3 months and a serious fall: a fall resulting in limited activities for at least 1 day or requiring medical attention.
A total of 5996 subjects were included in this analysis; 17.6% (n = 1055) reported falling 1 to 5 times in the previous 3 months, and 361 (6%) experienced serious falls. Risk of falling had a significant positive association among respondents who rated their general health as fair to poor (relative risk [RR] 2.39, 95% confidence interval [CI] 1.55-3.68) and a negative association for those who reported regular physical activity (RR 0.59, 95% CI 0.42-0.82). A similar model examined the risk of serious falls and found statistically positive associations in respondents who reported fair or poor general health (RR 3.29, 95% CI 2.00-5.43). Negative associations were found for those who reported regular physical activity (RR 0.56, 95% CI 0.38-0.83) and for men (RR 0.62, 95% CI 0.39-0.98). No statistically significant correlations for either of the fall outcomes were found with residence, obesity, education, income, age, ethnicity, employment, marital status, diabetes mellitus, or cardiovascular disease.
Interventions aimed at the prevention of falls should focus on maintaining and improving general health and promoting physical activity among older adults.

Introduction:
One out of three persons aged 65 and older falls annually and 20% to 30% of falls result in injury. The purpose of this cost-benefit analysis was to identify community-based fall interventions that were feasible, effective, and provided a positive return on investment (ROI).
Methods:
A third-party payer perspective was used to determine the costs and benefits of three effective fall interventions. Intervention effectiveness was based on randomized controlled trial results. National data were used to estimate the average annual benefits from averting the direct medical costs of a fall. The net benefit and ROI were estimated for each of the interventions.
Results:
For the Otago Exercise Program delivered to persons aged 65 and older, the net benefit was $121.85 per participant and the ROI was 36% for each dollar invested. For Otago delivered to persons aged 80 and older, the net benefit was $429.18 and the ROI was 127%. Tai chi: Moving for Better Balance had a net benefit of $529.86 and an ROI of 509% and Stepping On had a net benefit of $134.37 and an ROI of 64%.
Conclusions:
All three fall interventions provided positive net benefits. The ROIs showed that the benefits not only covered the implementation costs but also exceeded the expected direct program delivery costs. These results can help health care funders and other community organizations select appropriate and effective fall interventions that also can provide positive returns on investment.

Falling is the most frequent cause of injury in older adults in the United States, leading to substantial disability and mortality. A variety of studies have found that approximately one-third of older adults fall each year, but there have been no nationally representative longitudinal studies that examine falling across the population over time.¹ Falling is anticipated to increase in the United States owing to changing demography. However, a prior statewide study showed a temporal increase (1999-2001) in the annual rate of falls requiring medical care, independent of age.² We investigated temporal trends in falling on a national scale from 1998 to 2010, hypothesizing that any increase in prevalence would be due to changes in the age structure of the population.

Background:
Fear of falling is common in older people and associated with serious physical and psychosocial consequences. Exercise (planned, structured, repetitive and purposive physical activity aimed at improving physical fitness) may reduce fear of falling by improving strength, gait, balance and mood, and reducing the occurrence of falls.
Objectives:
To assess the effects (benefits, harms and costs) of exercise interventions for reducing fear of falling in older people living in the community.
Search methods:
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (July 2013), the Central Register of Controlled Trials (CENTRAL 2013, Issue 7), MEDLINE (1946 to July Week 3 2013), EMBASE (1980 to 2013 Week 30), CINAHL (1982 to July 2013), PsycINFO (1967 to August 2013), AMED (1985 to August 2013), the World Health Organization International Clinical Trials Registry Platform (accessed 7 August 2013) and Current Controlled Trials (accessed 7 August 2013). We applied no language restrictions. We handsearched reference lists and consulted experts.
Selection criteria:
We included randomised and quasi-randomised trials that recruited community-dwelling people (where the majority were aged 65 and over) and were not restricted to specific medical conditions (e.g. stroke, hip fracture). We included trials that evaluated exercise interventions compared with no intervention or a non-exercise intervention (e.g. social visits), and that measured fear of falling. Exercise interventions were varied; for example, they could be 'prescriptions' or recommendations, group-based or individual, supervised or unsupervised.
Data collection and analysis:
Pairs of review authors independently assessed studies for inclusion, assessed the risk of bias in the studies and extracted data. We combined effect sizes across studies using the fixed-effect model, with the random-effect model used where significant statistical heterogeneity was present. We estimated risk ratios (RR) for dichotomous outcomes and incidence rate ratios (IRR) for rate outcomes. We estimated mean differences (MD) where studies used the same continuous measures and standardised mean differences (SMD) where different measures or different formats of the same measure were used. Where possible, we performed various, usually prespecified, sensitivity and subgroup analyses.
Main results:
We included 30 studies, which evaluated 3D exercise (Tai Chi and yoga), balance training or strength and resistance training. Two of these were cluster-randomised trials, two were cross-over trials and one was quasi-randomised. The studies included a total of 2878 participants with a mean age ranging from 68 to 85 years. Most studies included more women than men, with four studies recruiting women only. Twelve studies recruited participants at increased risk of falls; three of these recruited participants who also had fear of falling.Poor reporting of the allocation methods in the trials made it difficult to assess the risk of selection bias in most studies. All of the studies were at high risk of performance and detection biases as there was no blinding of participants and outcome assessors and the outcomes were self reported. Twelve studies were at high risk of attrition bias. Using GRADE criteria, we judged the quality of evidence to be 'low' for fear of falling immediately post intervention and 'very low' for fear of falling at short or long-term follow-up and all other outcomes.Exercise interventions were associated with a small to moderate reduction in fear of falling immediately post intervention (SMD 0.37 favouring exercise, 95% confidence interval (CI) 0.18 to 0.56; 24 studies; 1692 participants, low quality evidence). Pooled effect sizes did not differ significantly between the different scales used to measure fear of falling. Although none of the sensitivity analyses changed the direction of effect, the greatest reduction in the size of the effect was on removal of an extreme outlier study with 73 participants (SMD 0.24 favouring exercise, 95% CI 0.12 to 0.36). None of our subgroup analyses provided robust evidence of differences in effect in terms of either the study primary aim (reduction of fear of falling or other aim), the study population (recruitment on the basis of increased falls risk or not), the characteristics of the study exercise intervention or the study control intervention (no treatment or alternative intervention). However, there was some weak evidence of a smaller effect, which included no reduction, of exercise when compared with an alternative control.There was very low quality evidence that exercise interventions may be associated with a small reduction in fear of falling up to six months post intervention (SMD 0.17, 95% CI -0.05 to 0.38; four studies, 356 participants) and more than six months post intervention (SMD 0.20, 95% CI -0.01 to 0.41; three studies, 386 participants).Very low quality evidence suggests exercise interventions in these studies that also reported on fear of falling reduced the risk of falling measured either as participants incurring at least one fall during follow-up or the number of falls during follow-up. Very low quality evidence from four studies indicated that exercise interventions did not appear to reduce symptoms of depression or increase physical activity. The only study reporting the effects of exercise interventions on anxiety found no difference between groups. No studies reported the effects of exercise interventions on activity avoidance or costs. It is important to remember that our included studies do not represent the totality of the evidence of the effect of exercise interventions on falls, depression, anxiety or physical activity as our review only includes studies that reported fear of falling.
Authors' conclusions:
Exercise interventions in community-dwelling older people probably reduce fear of falling to a limited extent immediately after the intervention, without increasing the risk or frequency of falls. There is insufficient evidence to determine whether exercise interventions reduce fear of falling beyond the end of the intervention or their effect on other outcomes. Although further evidence from well-designed randomised trials is required, priority should be given to establishing a core set of outcomes that includes fear of falling for all trials examining the effects of exercise interventions in older people living in the community.

Falls are the main cause of accidental death in the elderly people, which is associated with balance control ability and flexibility of the older adults. The purpose of this study was to evaluate the effect of Tai Chi Chuan (TCC) on the balance control and flexibility of the older adults.Methods
We searched the PubMed, Embase and Cochrane library with the deadline of May 15th, 2014. This meta-analysis was performed using RevMan5.0 software. The overall weighted mean difference (WMD) and its 95% confidence interval (CI) were calculated.ResultsA total of 7 randomized controlled trials including 1088 participants (544 TCC practitioners and 544 participants with other interventions) were considered in this meta-analysis. The pooled estimate of Get Up and Go test (WMD = 1.04; 95%CI: 0.67-1.41; P<0.0001) indicated that TCC significantly shorten the completion time of Get Up and Go test of the older adults, indicating flexibility of older adults was improved by practicing TCC. The overall estimates of the single-leg stand test (WMD = 5.33; 95%CI: 3.35-7.32; P<0.0001) and Berg (balance) test (WMD = 2.86; 95%CI: 1.91-3.81; P<0.0001) indicated that TCC could significantly prolong the time of single-leg stand and improve the balance control ability of older adults.Conclusions
In conclusion, TCC practice was beneficial to improve the balance control ability and flexibility of older adults, which may be the reason of preventing falls.

Background
The grading of recommendation, assessment, development and evaluation (GRADE) approach is widely implemented in health technology assessment and guideline development organisations throughout the world. GRADE provides a transparent approach to reaching judgements about the quality of evidence on the effects of a health care intervention, but is complex and therefore challenging to apply in a consistent manner.
Methods
We developed a checklist to guide the researcher to extract the data required to make a GRADE assessment. We applied the checklist to 29 meta-analyses of randomised controlled trials on the effectiveness of health care interventions. Two reviewers used the checklist for each paper and used these data to rate the quality of evidence for a particular outcome.
Results
For most (70%) checklist items, there was good agreement between reviewers. The main problems were for items relating to indirectness where considerable judgement is required.
Conclusions
There was consistent agreement between reviewers on most items in the checklist. The use of this checklist may be an aid to improving the consistency and reproducibility of GRADE assessments, particularly for inexperienced users or in rapid reviews without the resources to conduct assessments by two researchers independently.

Question: Can exercise or physical training improve physical function and prevent falls in older adults with visual impairments? Design: Systematic review of randomised controlled trials with meta-analysis. Participants: Older adults (≥ 60 years) with visual impairments. Intervention: Individual or group exercise or physical training classes in any settings. Outcome measures: Mobility, balance, strength and proprioception measured with performance tests or questionnaires and/or falls with calendars or incident reports. Results: Four eligible trials with a total of 522 participants were identified. Multimodal group exercise (n = 50 and 41) and Tai Chi (n = 40) improved physical function among residents of care settings. Meta-analysis of data from two trials indicated a significant positive impact of multimodal exercise on the Berg Balance Score (weighted mean difference 3.9 points, 95% CI 1.8 to 6.0), but not on the Timed Up and Go test (weighted mean difference 1.5 seconds, 95% CI –1.7 to 4.6). One trial (n = 41) found that multimodal exercise reduced the time to first fall (p = 0.049). A factorial trial (n = 391) among community dwellers did not find a significant effect on falls from a home-based exercise intervention, although clinically relevant effects in either direction were not excluded by the study (incidence rate ratio = 1.15, 95% CI 0.82 to 1.61). Conclusion: Exercise interventions in residential care settings improve performance on some tests of physical function that are risk factors for falls but the impact on falls is not yet clear. The impact of exercise and training on physical function and falls in community-dwelling older adults with visual impairments also warrants further investigation.
[Gleeson M, Sherrington C, Keay L (2014) Exercise and physical training improve physical function in older adults with visual impairments but their effect on falls is unclear: a systematic review.Journal of Physiotherapy60:XXX-XXX.]

Abstract Falls amongst older people is a global public health concern. Whilst falling is not a typical feature of ageing, older people are more likely to fall. Fall injuries amongst older people are a leading cause of death and disability. Many older people do not do regular exercise so that they lose muscle tone, strength, and flexibility which affect balance and predispose them to falls. The management of falls in residential care settings is a major concern with strategies for prevention and monitoring a focus in this setting. Yoga and tai chi have shown potential to improve balance and prevent falls in older adults. They also have potential to improve pain and quality of life. The aim of this study was to determine the feasibility of conducting a 3-arm RCT with frail older people in a residential care setting to test the hypothesis that a 14 week modified tai chi or yoga program is more effective than usual care activity in improving balance function, quality of life, pain experience and in reducing number of falls. There were no statistically significant differences between the three groups in the occurrence of falls. Yoga demonstrated a slight decrease in fall incidence; quality of life improved for the tai chi group. Only the yoga group experienced a reduction in average pain scores though not statistically significant. The findings of the study suggest it is possible to safely implement modified yoga and tai chi in a residential care setting and evaluate this using RCT design. They show positive changes to balance, pain and quality of life and a high level of interest through attendance amongst the older participants. The results support offering tai chi and yoga to older people who are frail and dependent with physical and cognitive limitations.

Background
Falls are the leading cause of injury death in older adults and present a significant public health problem and a major burden to healthcare. Although there is sufficient evidence from randomized controlled trials to indicate that exercise can prevent falls in older people, few effective, evidence-based fall prevention programs exist in community practice. Thus, there is a pressing need to translate and disseminate evidence-based exercise programs to community providers that serve older adults at increased risk of falling. The current study addresses this public health need by disseminating the evidence-based Tai Ji Quan: Moving for Better Balance (TJQMBB) program through community senior centers.
Methods/Design
The study uses a single-group design in which the TJQMBB program is being delivered to community-dwelling older adults through collaboration with senior centers in selected counties in Oregon, USA, for 48 weeks, followed by a 24-week post-intervention follow-up. Study process and outcome measures will be evaluated in accordance with the components of the RE-AIM framework that focus on Reach, Effectiveness, Adoption, Implementation and Maintenance.
Discussion
This study will determine whether the evidence-based TJQMBB fall prevention program can be disseminated through a broad spectrum of community-based senior centers that often cater to low-income, underserved community-dwelling older adults at risk of falling. If shown to be both practically implementable and sustainable, the TJQMBB program will provide an effective, potentially low-cost, easy-to-implement intervention that could be used by public health practitioners and community-based organizations to address the problem of falls among older adults.
Trial registration
ClinicalTrials.gov Identifier: NCT01854931

Falls in older adults, which often result from decreased balance and mobility, are an important public health issue. The American College of Sports Medicine recommends multidimensional balance and mobility training to prevent falls. In the past 20 years, Tai Chi Chu'an (tai chi) has been found to be effective in improving balance, reducing falls and fear of falling for older adults. Efficient use of time devoted to exercise is critical; therefore, more research is needed into the underlying mechanisms of balance and mobility improvements in older adults as a result of tai chi practice, so that these interventions can be most targeted and efficient. The purpose of this integrative review is twofold. First, evidence is presented to show that balance and mobility have been improved by tai chi in older adults. Second, potential mechanisms of balance improvement from research conducted in longtime tai chi practitioners, and from clinical research conducted in older adults, are offered. A PubMed search with the terms "tai chi" and "balance" entered simultaneously was conducted. Articles were included if they were systematic reviews, pilot or clinical trials, related to both balance and tai chi, and/or specifically related to determining the mechanisms potentially underlying tai chi's effects. The systematic reviews and meta-analyses show that aspects of tai chi research findings remain equivocal. In spite of the inconclusiveness of these review findings, many researchers have considered tai chi worthy of further investigation. Furthermore, practitioners in the clinic and those who deliver exercise in the community have evidently embraced tai chi as an appropriate exercise for older adults. This review, spanning 2 decades, suggests that tai chi has impacted the health and health behaviors of many older adults. Going forward, informing novel balance and mobility rehabilitation by uncovering mechanisms of tai chi's effects definitively may be the most important area of discovery in this field.

To determine whether, and to what extent, fall prevention exercise interventions for older community dwelling people are effective in preventing different types of fall related injuries.
Electronic databases (PubMed, the Cochrane Library, Embase, and CINAHL) and reference lists of included studies and relevant reviews from inception to July 2013.
Randomised controlled trials of fall prevention exercise interventions, targeting older (>60 years) community dwelling people and providing quantitative data on injurious falls, serious falls, or fall related fractures.
Based on a systematic review of the case definitions used in the selected studies, we grouped the definitions of injurious falls into more homogeneous categories to allow comparisons of results across studies and the pooling of data. For each study we extracted or calculated the rate ratio of injurious falls. Depending on the available data, a given study could contribute data relevant to one or more categories of injurious falls. A pooled rate ratio was estimated for each category of injurious falls based on random effects models.
17 trials involving 4305 participants were eligible for meta-analysis. Four categories of falls were identified: all injurious falls, falls resulting in medical care, severe injurious falls, and falls resulting in fractures. Exercise had a significant effect in all categories, with pooled estimates of the rate ratios of 0.63 (95% confidence interval 0.51 to 0.77, 10 trials) for all injurious falls, 0.70 (0.54 to 0.92, 8 trials) for falls resulting in medical care, 0.57 (0.36 to 0.90, 7 trials) for severe injurious falls, and 0.39 (0.22 to 0.66, 6 trials) for falls resulting in fractures, but significant heterogeneity was observed between studies of all injurious falls (I(2)=50%, P=0.04).
Exercise programmes designed to prevent falls in older adults also seem to prevent injuries caused by falls, including the most severe ones. Such programmes also reduce the rate of falls leading to medical care.

The Cochrane Handbook for Systematic Reviews of Interventions (the Handbook) has undergone a substantial update, and Version 5 of the Handbook is now available online at www.cochrane-handbook.org and in RevMan 5. In addition, for the first time, the Handbook will soon be available as a printed volume, published by Wiley-Blackwell. We are anticipating release of this at the Colloquium in Freiburg. Version 5 of the Handbook describes the new methods available in RevMan 5, as well as containing extensive guidance on all aspects of Cochrane review methodology. It has a new structure, with 22 chapters divided into three parts. Part 1, relevant to all reviews, introduces Cochrane reviews, covering their planning and preparation, and their maintenance and updating, and ends with a guide to the contents of a Cochrane protocol and review. Part 2, relevant to all reviews, provides general methodological guidance on preparing reviews, covering question development, eligibility criteria, searching, collecting data, within-study bias (including completion of the Risk of Bias table), analysing data, reporting bias, presenting and interpreting results (including Summary of Findings tables). Part 3 addresses special topics that will be relevant to some, but not all, reviews, including particular considerations in addressing adverse effects, meta-analysis with non-standard study designs and using individual participant data. This part has new chapters on incorporating economic evaluations, non-randomized studies, qualitative research, patient-reported outcomes in reviews, prospective meta-analysis, reviews in health promotion and public health, and the new review type of overviews of reviews.

Purpose:
To compare the effectiveness of supervised Tai Chi exercises versus the conventional physical therapy exercises in a personalized rehabilitation program in terms of the incidence and severity of falls in a frail older population.
Method:
The participants were frail older adults living in the community, admitted to the day hospital program in Sherbrooke, Quebec, Canada (n = 152). They were randomized to receive a 15-week intervention, either by supervised Tai Chi exercises (n = 76) or conventional physical therapy (n = 76). Fall incidence and severity were assessed using both the calendar technique and phone interviews once a month during 12 months following the end of the intervention. Other variables were collected at baseline to compare the two groups: age, comorbidity, balance, sensory interaction on balance, and self-rated health.
Results:
Both interventions demonstrated a protective effect on falls but Tai Chi showed a greater one (RR = 0.74; 95% CI = 0.56-0.98) as compared to conventional physical therapy exercises.
Conclusions:
Supervised Tai Chi exercises as part of a rehabilitation program seem to be a more effective alternative to the conventional physical therapy exercises for this specific population.

Objectives:
Falls are one of the leading causes of fractures and impaired quality of life in the elderly, and they are related to balance deficit and to fear of falls. The purpose of our study is to evaluate predictors of falls in the 50-65-year-old postmenopausal population.
Methods:
A prospective cohort study was conducted on 96 postmenopausal women. Fear of falling and postural stability were assessed by using the FES-I (Falls Efficacy Scale-International) and a force platform, respectively. Fall frequency was determined in the 12-month follow-up study period. Multivariate logistic regression was used to identify predictive factors of falls.
Results:
Fear of falls, the FES-I scale and four stabilometric parameters, specifically under eyes-closed condition, were significantly higher in the group of fallers. The root mean square amplitude in the medial-lateral direction with eyes closed (RMSXec) (odds ratio 5.1, 95% confidence interval (CI) 1.6-15.5, p = 0.004) and FES-I (odds ratio 3.4, 95% CI 1.1-10.5, p = 0.026) were the best independent predictive factors of the risk of falling.
Conclusions:
RMSXec > 0.133 was the best predictive factor for falls in our group of 50-65-year-old postmenopausal women studied, and a FES-I score > 20 could predict falls in this population.

This study aimed to compare the effects of two exercise programs on balance and risk of falls in older women with age-related visual dysfunction.
Participants living in a residential home were randomly allocated to Group I (n=21) receiving a progressive, tailored multimodal exercise program in addition to the standard osteoporosis exercise program or Group II (n=20) receiving the standard osteoporosis exercise program alone. At baseline, and after the 6-month exercise program outcomes were measured.
After the exercise program there was significant between-group difference in favor of the Group I in Timed Up and Go (TUG) test (p=0.001), but not in Berg Balance score (p=0.130), and Barthel Activity Index (p=0.662). In Group I the risk of falls reduced by 46%, but this result was not significant (RR=0.54, 95% CI 0.294-1.007). The mean length of event-free time was significantly longer in the Group I than in Group II (18.5 weeks, 95% CI 15.4-21.7 vs. 14.8 weeks, 95% CI 11.1-18.4; p=0.049).
If the current osteoporosis guideline is applied for older adults with low vision, it would be worthwhile putting more emphasis on the inclusion of patient-tailored strength and balance exercises to improve balance and potentially reduce the risk of falls.

To evaluate the cost-effectiveness of strategies designed to prevent falls amongst people aged 65 years and over living in the community and in residential aged-care facilities.
A systematic review and meta-analysis of the literature was conducted. The pooled fall rate ratio was used in a decision analytic model that combined a Markov model and decision tree to estimate the costs and outcomes of potential interventions and/or strategies. The resulting cost per quality-adjusted life year was estimated.
The most cost-effective falls prevention strategy in community-dwelling older people was Tai Chi. Expedited cataract surgery and psychotropic medication withdrawal were also found to be cost-effective; however, the effectiveness of these interventions is less certain due to small numbers of trials and participants. The most cost-effective falls prevention strategies in residential aged-care facilities were medication review and vitamin D supplementation.

In the GRADE approach, randomized trials start as high-quality evidence and observational studies as low-quality evidence, but both can be rated down if most of the relevant evidence comes from studies that suffer from a high risk of bias. Well-established limitations of randomized trials include failure to conceal allocation, failure to blind, loss to follow-up, and failure to appropriately consider the intention-to-treat principle. More recently recognized limitations include stopping early for apparent benefit and selective reporting of outcomes according to the results. Key limitations of observational studies include use of inappropriate controls and failure to adequately adjust for prognostic imbalance. Risk of bias may vary across outcomes (e.g., loss to follow-up may be far less for all-cause mortality than for quality of life), a consideration that many systematic reviews ignore. In deciding whether to rate down for risk of bias--whether for randomized trials or observational studies--authors should not take an approach that averages across studies. Rather, for any individual outcome, when there are some studies with a high risk, and some with a low risk of bias, they should consider including only the studies with a lower risk of bias.

To model the population level impact of tai-chi on future rates of falls and fall-related injury in older people as a tool for policy development.
An epidemiological and economic model for estimating population-level effectiveness of tai-chi.
Australia, 2009. Patients or subjects Australian community-dwelling population aged 70+ years, ambulatory and without debilitating conditions or profound visual defects. Intervention Group-based tai-chi, for 1 h twice weekly for 26 weeks, assuming no sustained effect beyond the intervention period. Main outcome measure Total falls and fall-related hospitalisation prevented in 2009.
Population-wide tai-chi delivery would prevent an estimated 5440 falls and 109 fall-related hospitalisations, resulting in a 0.18% reduction in the fall-related hospital admission rate for community-dwelling older people. The gross costs per fall and per fall-related hospital admission prevented were $A4414 (€3013) and $A220,712 (€150,684), respectively. A total investment of $A24.01 million (€16.39 million), equivalent to 4.2% of the cost of fall-related episodes of hospital care in 2003/4, would be required to provide tai-chi for 31,998 people and achieve this effect.
Substantial investment in, and high population uptake of, tai-chi would be required to have a large effect on falls and fall-related hospitalisation rates. Although not accounted for in this study, investment in tai-chi is likely to be associated with additional significant health benefits beyond falls prevention. This approach could be applied to other interventions to assist selection of the most cost-effective falls-prevention portfolio for Australia and other countries.

Systematic reviews and meta-analyses are essential to summarize evidence relating to efficacy and safety of health care interventions accurately and reliably. The clarity and transparency of these reports, however, is not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users.
Since the development of the QUOROM (QUality Of Reporting Of Meta-analysis) Statement—a reporting guideline published in 1999—there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realizing these issues, an international group that included experienced authors and methodologists developed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions.
The PRISMA Statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this Explanation and Elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA Statement, this document, and the associated Web site (http://www.prisma-statement.org/) should be helpful resources to improve reporting of systematic reviews and meta-analyses.

Approximately 30% of people over 65 years of age living in the community fall each year.
To assess the effects of interventions to reduce the incidence of falls in older people living in the community.
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE, EMBASE, CINAHL, and Current Controlled Trials (all to May 2008).
Randomised trials of interventions to reduce falls in community-dwelling older people. Primary outcomes were rate of falls and risk of falling.
Two review authors independently assessed trial quality and extracted data. Data were pooled where appropriate.
We included 111 trials (55,303 participants).Multiple-component group exercise reduced rate of falls and risk of falling (rate ratio (RaR) 0.78, 95%CI 0.71 to 0.86; risk ratio (RR) 0.83, 95%CI 0.72 to 0.97), as did Tai Chi (RaR 0.63, 95%CI 0.52 to 0.78; RR 0.65, 95%CI 0.51 to 0.82), and individually prescribed multiple-component home-based exercise (RaR 0.66, 95%CI 0.53 to 0.82; RR 0.77, 95%CI 0.61 to 0.97).Assessment and multifactorial intervention reduced rate of falls (RaR 0.75, 95%CI 0.65 to 0.86), but not risk of falling.Overall, vitamin D did not reduce falls (RaR 0.95, 95%CI 0.80 to 1.14; RR 0.96, 95%CI 0.92 to 1.01), but may do so in people with lower vitamin D levels. Overall, home safety interventions did not reduce falls (RaR 0.90, 95%CI 0.79 to 1.03); RR 0.89, 95%CI 0.80 to 1.00), but were effective in people with severe visual impairment, and in others at higher risk of falling. An anti-slip shoe device reduced rate of falls in icy conditions (RaR 0.42, 95%CI 0.22 to 0.78).Gradual withdrawal of psychotropic medication reduced rate of falls (RaR 0.34, 95%CI 0.16 to 0.73), but not risk of falling. A prescribing modification programme for primary care physicians significantly reduced risk of falling (RR 0.61, 95%CI 0.41 to 0.91).Pacemakers reduced rate of falls in people with carotid sinus hypersensitivity (RaR 0.42, 95%CI 0.23 to 0.75). First eye cataract surgery reduced rate of falls (RaR 0.66, 95%CI 0.45 to 0.95).There is some evidence that falls prevention strategies can be cost saving.
Exercise interventions reduce risk and rate of falls. Research is needed to confirm the contexts in which multifactorial assessment and intervention, home safety interventions, vitamin D supplementation, and other interventions are effective.

To evaluate the effectiveness of Tai Chi Chuan in fall prevention in elderly people living at home with a high risk of falling.
Randomized controlled trial.
Two industrial towns in the western part of the Netherlands.
Two hundred sixty-nine elderly people (average age 77) living at home with a high risk of falling.
The intervention group received Tai Chi Chuan training for 1 hour twice a week for 13 weeks; the control group received usual care. Both groups received a brochure containing general information on how to prevent fall incidents.
Primary outcome was the number of falls over 12 months. Secondary outcomes were balance, fear of falling, blood pressure, heart rate at rest, forced expiratory volume during the first second, peak expiratory flow, physical activity, and functional status.
After 12 months, no lower fall risk in the Tai Chi Chuan group was observed than in the control group (adjusted hazard ratio=1.16; 95% confidence interval=0.84-1.60), and there were no significant intervention effects on the secondary outcome measures.
These results suggest that Tai Chi Chuan may not be effective in elderly people at a high risk of falling who live at home.

To evaluate the effects of two exercise approaches, Tai Chi (TC) and computerized balance training (BT), on specified primary outcomes (biomedical, functional, and psychosocial indicators of frailty) and secondary outcomes (occurrence of falls).
The Atlanta FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques), a prospective, randomized, controlled clinical trial with three arms (TC, BT, and education [ED]. Intervention length was 15 weeks, with primary outcomes measured before and after intervention and at 4-month follow-up. Falls were monitored continuously throughout the study.
Persons aged 70 and older living in the community.
A total of 200 participants, 162 women and 38 men; mean age was 76.2.
Biomedical (strength, flexibility, cardiovascular endurance, body composition), functional (IADL), and psychosocial well-being (CES-D scale, fear of falling questionnaire, self-perception of present and future health, mastery index, perceived quality of sleep, and intrusiveness) variables.
Grip strength declined in all groups, and lower extremity range of motion showed limited but statistically significant changes. Lowered blood pressure before and after a 12-minute walk was seen following TC participation. Fear of falling responses and intrusiveness responses were reduced after the TC intervention compared with the ED group (P = .046 and P = .058, respectively). After adjusting for fall risk factors, TC was found to reduce the risk of multiple falls by 47.5%.
A moderate TC intervention can impact favorably on defined biomedical and psychosocial indices of frailty. This intervention can also have favorable effects upon the occurrence of falls. Tai Chi warrants further study as an exercise treatment to improve the health of older people.

We study recently developed nonparametric methods for estimating the number of missing studies that might exist in a meta-analysis and the effect that these studies might have had on its outcome. These are simple rank-based data augmentation techniques, which formalize the use of funnel plots. We show that they provide effective and relatively powerful tests for evaluating the existence of such publication bias. After adjusting for missing studies, we find that the point estimate of the overall effect size is approximately correct and coverage of the effect size confidence intervals is substantially improved, in many cases recovering the nominal confidence levels entirely. We illustrate the trim and fill method on existing meta-analyses of studies in clinical trials and psychometrics.

Heterogeneity between study results can be a problem in any systematic review or meta-analysis of clinical trials. Identifying its presence, investigating its cause and correctly accounting for it in analyses all involve difficult decisions for the researcher. Our objectives were: to collate recommendations on the subject of dealing with heterogeneity in systematic reviews of clinical trials; to investigate current practice in addressing heterogeneity in Cochrane reviews; and to compare current practice with recommendations.
We review guidelines for those undertaking systematic reviews and examine how heterogeneity is addressed in practice in a sample of systematic reviews, and their protocols, from the Cochrane Database of Systematic Reviews.
Advice to reviewers is on the whole consistent and sensible. However, examination of a sample of Cochrane protocols and reviews demonstrates that the advice is difficult to follow given the small numbers of studies identified in many systematic reviews, the difficulty of pre-specifying important effect modifiers for subgroup analysis or meta-regression and the unresolved debate concerning fixed versus random effects meta-analyses. There was disagreement between protocols and reviews, often either regarding choice of important potential effect modifiers or due to the review identifying too few studies to perform planned analyses.
Guidelines that address practical issues are required to reduce the risk of spurious findings from investigations of heterogeneity. This may involve discouraging statistical investigations such as subgroup analyses and meta-regression, rather than simply adopting a cautious approach to their interpretation, unless a large number of studies is available. The notion of a priori specification of potential effect modifiers for a retrospective review of studies is ill-defined, and the appropriateness of using a statistical test for heterogeneity to decide between analysis strategies is suspect.

The authors' objective was to evaluate the efficacy of a 6-month Tai Chi intervention for decreasing the number of falls and the risk for falling in older persons.
This randomized controlled trial involved a sample of 256 physically inactive, community-dwelling adults aged 70 to 92 (mean age, 77.48 years; standard deviation, 4.95 years) who were recruited through a patient database in Portland, Oregon. Participants were randomized to participate in a three-times-per-week Tai Chi group or to a stretching control group for 6 months. The primary outcome measure was the number of falls; the secondary outcome measures included functional balance (Berg Balance Scale, Dynamic Gait Index, Functional Reach, and single-leg standing), physical performance (50-foot speed walk, Up&Go), and fear of falling, assessed at baseline, 3 months, 6 months (intervention termination), and at a 6-month postintervention follow-up.
At the end of the 6-month intervention, significantly fewer falls (n=38 vs 73; p=.007), lower proportions of fallers (28% vs 46%; p=.01), and fewer injurious falls (7% vs 18%; p=.03) were observed in the Tai Chi group compared with the stretching control group. After adjusting for baseline covariates, the risk for multiple falls in the Tai Chi group was 55% lower than that of the stretching control group (risk ratio,.45; 95% confidence interval, 0.30 to 0.70). Compared with the stretching control participants, the Tai Chi participants showed significant improvements (p<.001) in all measures of functional balance, physical performance, and reduced fear of falling. Intervention gains in these measures were maintained at a 6-month postintervention follow-up in the Tai Chi group.
A three-times-per-week, 6-month Tai Chi program is effective in decreasing the number of falls, the risk for falling, and the fear of falling, and it improves functional balance and physical performance in physically inactive persons aged 70 years or older.

To determine the effects of moderate intensity group-exercise programs on falls, functional performance, and disability in older adults; and to investigate the influence of frailty on these effects.
A 20-week, multicenter randomized controlled trial, with 52-week follow-up.
Fifteen homes for the elderly.
Two hundred seventy-eight men and women (mean age +/- standard deviation, 85+/-6y).
Two exercise programs were randomly distributed across 15 homes. The first program, functional walking (FW), consisted of exercises related to daily mobility activities. In the second program, in balance (IB), exercises were inspired by the principles of Tai Chi. Within each home participants were randomly assigned to an intervention or a control group. Participants in the control groups were asked not to change their usual pattern of activities. The intervention groups followed a 20-week exercise program with 1 meeting a week during the first 4 weeks and 2 meetings a week during the remaining weeks.
Falls, Performance Oriented Mobility Assessment (POMA), physical performance score, and the Groningen Activity Restriction Scale (GARS) (measuring self-reported disability).
Fall incidence rate was higher in the FW group (3.3 falls/y) compared with the IB (2.4 falls/y) and control (2.5 falls/y) groups, but this difference was not statistically significant. The risk of becoming a faller in the exercise groups increased significantly in the subgroup of participants who were classified as being frail (hazard ratio [HR] = 2.95; 95% confidence interval [CI], 1.64-5.32). For participants who were classified as being pre-frail, the risk of becoming a faller decreased; this effect became significant after 11 weeks of training (HR = .39; 95% CI, .18-.88). Participants in both exercise groups showed a small, but significant improvement in their POMA and physical performance scores. In the FW group, this held true for the GARS score as well. Post hoc analyses revealed that only the pre-frail participants improved their POMA and physical performance scores.
Fall-preventive moderate intensity group-exercise programs have positive effects on falling and physical performance in pre-frail, but not in frail elderly.

The beneficial role of exercise in improving bone mineral density, muscle strength and balance, has been documented predominantly in younger populations. These findings may not apply to elderly populations with limited ability to perform exercises of high intensity.
To examine the effects of Tai Chi (TC) and resistance exercise (RTE) on bone mineral density (BMD), muscle strength, balance and flexibility in community living elderly people.
Randomised controlled trial, using blocked randomization with stratification by sex.
A community in the New Territories Region of Hong Kong, China.
One hundred eighty subjects (90 men, 90 women) aged 65-74, were recruited through advertisements in community centres.
Subjects were assigned to participate in TC, RTE three times a week, or no intervention (C) for 12 months. Measurements were carried out at baseline, 6 and 12 months. Analyses of covariance (ANCOVA) adjusted for age, and baseline values of variables that were significantly different between groups: i.e. smoking and flexibility for men; quadriceps strength for women.
Compliance was high (TC 81%, RTE 76%). In women, both TC and RTE groups had less BMD loss at total hip compared with controls. No effect was observed in men. No difference in either balance, flexibility or the number of falls was observed between either intervention or controls after 12 months.
The beneficial effects of TC or RTE on musculoskeletal health are modest and may not translate into better clinical outcomes.

To determine the effectiveness of a 16-week community-based tai chi program in reducing falls and improving balance in people aged 60 and older.
Randomized, controlled trial with waiting list control group.
Community in Sydney, Australia.
Seven hundred two relatively healthy community-dwelling people aged 60 and older (mean age 69).
Sixteen-week program of community-based tai chi classes of 1 hour duration per week.
Falls during 16 and 24 weeks of follow-up were assessed using a calendar method. Balance was measured at baseline and 16-week follow-up using six balance tests.
Falls were less frequent in the tai chi group than in the control group. Using Cox regression and time to first fall, the hazard ratio after 16 weeks was 0.72 (95% confidence interval (CI)=0.51-1.01, P=.06), and after 24 weeks it was 0.67 (95% CI=0.49-0.93, P=.02). There was no difference in the percentage of participants who had one or more falls. There were statistically significant differences in changes in balance favoring the tai chi group on five of six balance tests.
Participation in once per week tai chi classes for 16 weeks can prevent falls in relatively healthy community-dwelling older people.

Objective: To systematically evaluate the effectiveness of fall prevention and balance function in the elderly.
Methods: Databases, including PubMed, Web of Science, Cochrane Library, Chinese Biomedical Literature Database (CBM), and CNKI were electronically searched, and the relevant references of the included papers were also manually searched. Two reviewers independently screened the articles ... [Show full abstract] according to the inclusion and exclusion criteria, extracted the data, and assessed the methodological quality. A meta-analysis was performed using the Cochrane Collaboration's RevMan 5.1 software.
Results: Six randomized controlled trials (RCTs) involving 2796 participants were included. The results of the meta-analysis showed that compared with a physiotherapy intervention, Tai Chi could significantly reduce the incidence rates of falls [relative risk (RR) = 0.82, 95% confidence interval (CI) (0.73, 0.92)], while there were significant differences in the Timed Up and Go test, Functional Reach Test and Berger Balance Scale.
Conclusions: Tai Chi is effective in reducing the risk of falls and improving balance in the elderly.